THE JOURNAL O F NURSING ADMINISTRATION A

THE JOURNAL O F NURSING ADMINISTRATION A Tale of 2 Units Lessons in Changing the Care Delivery Model by: Glenda Wharton, MSN, RN, NE-BC, CENP Jill Berger, MSN, MBA, RN, NE-BC Tracy Williams, DNP, RN please summarize the journal In response to patient care quality and satisfaction concerns, a hospital determined the need to change the care delivery model on some inpatient units. Two pilot units adopted 2 different models of care. The authors describe the change project, successful outcomes, and lessons learned. The American Organization of Nurse Executives (AONE) describes the care delivery system of the future as having vast complexity owing to sophisticated technology and growth in chronic health issues, as well as diversity in patient populations and healthcare settings.1 To meet the demands of this complex system, AONE calls upon nurse leaders to enlist the help of direct care nurses in redesigning patient centered care across the continuum, optimizing nursing roles, focusing on outcomes, and reorganizing workflow and resources to increase efficiency, decrease cost, and improve quality. The Institute of Medicine (IOM) suggests that nurses should be full partners with other healthcare professionals in redesigning America_s increasingly complex healthcare system.2 The American Nurses Association agrees and acknowledges the need for nurses to take a leadership role in all settings to meet the demands of a changing healthcare system.3 The chief nursing officer must become the catalyst for Author Affiliations: Director of Patient Care Services (Ms Wharton), Norton Audubon Hospital; Director of Patient Care Operations (Ms Berger), Norton Healthcare Institute for Nursing; System Senior Vice President and Chief Nursing Officer (Dr Williams), Norton Healthcare, Louisville, Kentucky. The authors declare no conflicts of interest. Correspondence: Ms Wharton, Norton Audubon Hospital, One Audubon Plaza Dr, Louisville, KY 40217 (Glenda.wharton@ nortonhealthcare.org). DOI: 10.1097/NNA.0000000000000323 change, using the care delivery model (CDM) as an instrument for change.4,5 There is significant pressure on healthcare organizations and systems in the United States to deliver products, services, and outcomes that are high quality, service oriented, and value added. The increased focus on economics in the provision of care to patients, communities, and populations will yield renewed emphasis on reducing costs in hospitals, systems, and nursing. Cost of care is one of the future economic indicators that will determine organizational effectiveness. Because the predominant expense in nursing and patient care areas is labor, patient care operations have traditionally addressed cost, in part, through the use of productivity systems that focus on expense measured by hours per patient day or other indicator of volume or activity. Organizations typically create a fixed and variable standard for each unit or department upon which care is based. This standard yields a staffing and personnel budget. Productivity systems typically create a Bone-size-fits-all[ standard for similar units and departments (ie, medical/surgical units, telemetry units, intensive care units, emergency departments, etc). These standards create simplicity but usually do not address the needs and variability in different patient populations. Reducing cost through the use of productivity systems arbitrarily reduces hours of care provided within a unit or department. The way care is delivered is usually not addressed when those reductions are made; thus, this methodology is not ideal for patients or caregivers. According to the IOM, elimination of barriers for all professions with a focus on collaborative teamwork will maximize and improve care throughout the healthcare system.2 Lack of teamwork was cited by the IOM as 1 cause of preventable medical errors 176 JONA Vol. 46, No. 4 April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. that lead to nearly 100,000 patient deaths each year.6 Communication failure is a common factor in sentinel events.7 Communication failures lead to medical errors and negatively impact patient and staff satisfaction and healthcare costs.8 There is an urgent need to develop and sustain environments of care that foster quality outcomes and patient safety. Teamwork, communication, and collaboration are mandatory for patient safety and quality7,8 and thus critical elements of any CDM. Breakdowns in communication and dysfunctional teamwork among members of the nursing teamVregistered nurses (RNs), licensed practical nurses (LPNs), nursing assistants (NAs), and unit secretaries (USs)Vare pervasive on nursing units.9 The size and layout of the unit can prevent coworkers from interacting, seeing what others are doing or noticing that backup is needed, thus leading to dysfunction. Missed nursing care is a quality and safety concern in acute care. Kalisch and Lee10 describe a study of 2,216 nursing staff members on 50 acute care patient units in 4 hospitals in which teamwork alone accounted for about 11% of missed nursing care. Further study pointed to a lack of essential elements of teamwork, including closed-loop communication, leadership, team orientation, trust, and shared mental models.11 Nurses in direct care and leadership must work together to develop CDMs that maximize efficient use of licensed and unlicensed personnel to the full extent of their education and scope of practice, while emphasizing teamwork, communication, and collaboration. To address this imperative, a 5-hospital system in the mid-south undertook a clinical transformation initiative focused on designing the appropriate unit level models of care that would create the right care delivery system for the right patients with the right caregivers while reducing the cost per unit of service. The initiative involved 20 units across the hospital system representing all clinical subspecialties (ie, intensive care unit [ICU], medical, telemetry, orthopedic, surgical, oncology, emergency department, operating room, and labor and delivery) collectively serving as a redesign laboratory. Goals and outcome metrics were defined at the system level and a baseline assessment of each unit was completed. Metrics focused on quality, safety, service, staff engagement, staff turnover, and cost per unit of service. Nurses at a 264-bed community hospital in the system had already conducted a pilot and redesigned the model of care on 2 nursing units, with positive results in clinical outcomes and patient satisfaction. The nursing leaders in this hospital became mentors to their counterparts in the other hospitals. This article reports the findings of the pilot project involving these 2 units. The Pilot: A Tale of 2 Units After reviewing service excellence outcomes and patient comments and closely observing patient care practices on the units, the directors of the pilot hospital concluded that certain aspects of basic nursing care were missing and that communication between caregivers was inadequate. Nurses were not giving report to the NAs; instead, the NAs were giving report to one another. Nurses did not recognize themselves as leaders with the authority or responsibility to direct the work of the NAs. Instead, the units were operating with 2 parallel tracks of caregivers. There was a clear need to improve teamwork, communication, and coordination of care and get back to the basics. A charter was drafted for a performance improvement team using the DMAIC model (define, measure, analyze, improve, and control), a 6 Sigma methodology aimed at improving efficiency and eliminating defects.12 The team addressed the need to get back to basics, evaluating missed care events, focusing on communication between members of the healthcare team, and striving to ensure patient safety. The team surveyed direct care staff on every shift for a 7-day period regarding missed patient care. They used the MISSCARE survey, developed by Kalisch and Williams,13 with some added items of specific interest to the hospital, to better quantify the extent of missed care on the nursing units. Commonly reported missed care included toileting, bathing, oral care, turning patients, daily weights, glucose monitoring, and labs/ electrocardiogram, among others. Top reasons for missed care were poor communication, short staff, and lack of teamwork. These findings validated information obtained from patient satisfaction surveys and direct observation. To reduce the number of missed care events, the team developed a task list to clarify the NA role expectations and an assignment sheet to be completed by the NA during shift report. A 2nd DMAIC team was commissioned to explore options for CDM changes. This team_s work focused on having the right caregivers in the right place at the right time and customizing the care to the needs of the patient population being served. Direct care nurses, nurse managers, and assistant nurse managers from each inpatient unit, not including ICU, populated the CDM team. A literature search was completed and lengthy discussions and debate ensued about the significance of educational preparation of RNs, the role of LPNs in acute care, scope of practice, and training needs. Much time was spent creating a critical paradigm shift among team members regarding the role of the LPN and the value of a baccalaureate degree for RNs. Ultimately, managers of 2 units volunteered to participate in a pilot for change in CDMs: unit A, JONA Vol. 46, No. 4 April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. 177 a surgical unit, and unit B, a monitored medicalsurgical unit. Design Phase As the teams brainstormed CDM options, their work was facilitated by the use of a design board tool. This magnetic whiteboard with color-coded poker chips gave them the flexibility to experiment with alternative staffing designs during team meetings. With this tool, they could create simulations allowing them to visualize and feel the impact of their design on the teams. By entering the designs into an electronic staffing grid, costs of the models were calculated and the financial impact of each was evaluated for feasibility. Studies demonstrate that surgical patients experience lower incidence of deep vein thrombosis, pulmonary embolism and post surgical mortality, and shorter length of stay in hospitals having higher proportions of nurses educated at the baccalaureate level or higher.14,15 On the basis of that information, unit A decided to use only RNs with a baccalaureate degree (BSN) or RNs who were in school pursuing a BSN in their model. Because of the high volume of pain medications and dressing changes, unit A agreed that the role of LPN would be well utilized in a team with a bachelor_s-prepared RN. Each RN-LPN team would manage a group of up to 10 patients. Nursing assistant support would be provided to the unit, and at the highest census numbers, an NA would be assigned for each RN-LPN team. Unit B chose a different model, adding more NAs because of the high level of personal care associated with their patient population. In this model, RNs would manage up to 7 patients and every RN would be paired with an NA for team nursing. In both models, caregivers would be assigned a buddy on the unit of the same skill set to cover for meals, breaks, and support. Both units would continue to be supported by the role of USs 7:00 AM to 7:00 PM, 7 days a week. Average salary for each unit_s bedside caregiver roles was used to project the cost of each new model at various census levels. This cost was compared with the current model at the same census levels. In both of the new models, there were cost savings at average census levels. Delineation of Roles A task list was developed to clearly understand the work currently being done and to identify what was being accomplished by each role. The list was then sorted and redistributed to avoid nurses doing work that others could do and ensure that each member of the care team would be working to the full extent of his/her skills and training. Functions of the RN were identified, such as conducting assessments, developing care plans, establishing goals, and tracking progress, focusing on outcomes, providing education, managing the record, coordinating care, and facilitating transitions. The work of the LPN was more task focused, including passing medications, changing dressings, and starting intravenous (IV) lines. Provision of an LPN IV therapy class ensured that all LPNs were equally skilled to perform this task. Nursing assistants were assigned vital signs, bedside glucose monitoring, blood draws, daily weights, intake and output, and personal care. Adopting the Model An education plan, communication plan, and timeline were developed. Staff meetings were held on each unit to explain the plans for the models and to get additional staff input. Physicians and key stakeholders were informed about the models in advance of implementation. Descriptions of the models and the plans for go-live were published in a facility newsletter and communicated by e-mail. Unit A went live 1st. With the help and support of the human resources department, 11 LPNs from other inpatient units were transferred to unit A. Associate degree nurses from unit A, who were not currently in school, were transferred to another unit under the same management, and some BSNs from that unit were transferred to unit A. Individual meetings were held with those being transferred to explain the transitions and the expectations. As all positions were not filled before go-live, staff from the healthcare system_s internal agency were contracted to fill the gaps in the interim. Unit B did not transfer any nurses. Additional NA positions were posted on unit B and internal agency staff were contracted to temporarily fill some of the existing vacancies. Initial Staff Reactions Reactions to the models varied. On unit A, LPNs were not happy about leaving the units where they had been employed long-term or the perceived limitations on their scope of practice. The RNs were worried about their ability to do complete assessments on 10 patients. They were uncomfortable with the thought of delegating to LPNs, who previously managed a team of patients independently. The RNs on unit B were concerned with the potential to have 7 patients assigned and were not confident that delegating work to their own NA would make their workload manageable. Nursing assistants in this model were pleased that their previous assignments of 12 to 15 patients would now be limited to no more than 7 but were concerned that they would now be expected to increase their availability to patients while also addressing the more global needs of the department. 178 JONA Vol. 46, No. 4 April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. To address delegation concerns and provide further role clarification, RNs, LPNs, and NAs from both units attended a class on delegation before go-live. For the RNs to be leaders, they needed to learn how to delegate, and support staff needed to understand how to receive direction from the nurse. To further enhance delegation and role delineation, RNs began participating more actively in the orientation of the NAs. Adapting the Model Before go-live on each unit, nurses engaged in practice shifts, with 1 team performing the new model on a shift, then providing feedback on how it went. This allowed for modifications to the model before full unit implementation. Staff meetings were held in small groups on each unit to set forth expectations and field questions and get feedback from the practice shifts. During the 1st week, staff gathered at the change of shifts to talk about what went well and what did not. Some feedback resulted in immediate change; other suggestions were considered over the course of a month and adaptations to the model were made by group consensus. For example, on unit A, initially, nurses had planned to take their own vital signs (V/S). However, by the time they finished assessing all of their patients, the LPN was delayed in giving certain blood pressure medications. Taking V/S was then quickly delegated back to the NAs. Getting bedside shift report on 10 patients initially took too long. While speed improved with practice, the team decided to postpone review of orders until after bedside handoffs were finished. Initially, some of the LPNs on unit A expressed that they no longer felt autonomous in their practice. They were reminded that the initial assessments must be done and documented by an RN but they were still expected to use their assessment skills. Clarifying this point immediately improved the satisfaction of the LPNs. On unit B, the initial plan was to have the NAs participate in bedside shift report. This resulted in too many people at the bedside and not enough people available to respond to call lights while the handoff was occurring. The team decided to have the NAs proceed with their morning routine with a commitment from the RNs to give a brief report to their NA immediately after bedside reports were completed. Assignments were initially based on geography more than acuity. Based on feedback from the staff, the team decided to modify the way assignments were made. Two RNs working as buddies were assigned in contiguous geographic spaces and adjusted their assignments between the 2 teams by acuity. At the time of the model design, the team discussed that the night shift NAs_ workload was less demanding and that working with 1 less NA on night shift would be sufficient. After a few shifts, however, it was clear that keeping the integrity of the model design with an NA for every RN was important. The decision to have night shift NAs give some of the baths created a better balance in workloads between the 2 shifts. Outcomes Despite the initial staff concerns, teamwork and collaboration quickly improved on unit A. There were fewer call lights and significantly improved patient satisfaction scores, specifically with regard to pain management, response to needs, and nurse communications. In less than 3 months, the team was nimble and able to flex with volume and acuity demands and felt pride in their work. They were showcasing their model and providing shadowing opportunities for other nursing departments in the healthcare system considering using LPNs in their care delivery redesign plans. Table 1 provides preimplementation and postimplementation metrics for unit A, demonstrating the success of the model for this population of surgical patients. Patient satisfaction scores on unit B initially soared but quickly returned to previous lows. This unit initially went more than 50 days without a fall and initially hospital-acquired pressure ulcer rates decreased, but the nurses never fully adopted the buddy system and Table 1. Unit A Outcome Metrics Unit A Metric 2013: Preimplementation 2015: Postimplementation Quality: hospital-acquired pressure ulcers 10 4 Safety: falls per 1000 patient days 4.31 2.05 Service: nurse communication 72.6 74 Engagement: opportunity to do the things I do best 83 85 Engagement: overall I am satisfied with my job 83 95 Engagement: employees genuinely care about patients 90 95 Turnover: RN 20.5% 5.2% Turnover: all staff 31.2% 25% Financial: cost per patient day $306.43 $285.40 JONA Vol. 46, No. 4 April 2016 Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved. 179 continued to express concern about having 7-patient assignments, feeling that the workload was too much. Delegation skills remained a concern for nurses who were uncomfortable asking NAs to do tasks. Nurse satisfaction on the unit began to decline and turnover began to rise. After 6 months, the decision was made to abandon the 7-patient model and revert to a model providing more nurses than NAs and team assignments of 5 to 6 patients. Conclusion Unprecedented volume demands at the pilot hospital impacted the ability of both pilot units to staff to their models consistently. Although this caused significant hardship for the RNs on unit B trying to care for 7 patients, the RN/LPN model on unit A proved to be more resilient to staffing and volume fluctuations. Registered nurses in unit A prefer the new model and the way they organize their care over their previous model of care. New RNs report learning much from their experienced LPN colleagues and, with the support of the team, feel more confident in the care they are delivering. As the other 4 facilities in this hospital system moved forward with redesign of their CDMs, the experiences at the pilot hospital provided valuable insights. Leaders and members of the design teams gathered for roundtable discussions to learn what worked and what did not. A few lessons learned for improving teamwork and communication are the following: 1. Spend the necessary time to help practitioners shift their paradigms related to their roles and the roles of coworkers to create consistent mental models of teamwork among practitioners. This includes helping RNs understand the scope of their responsibilities for top-of-license performance as opposed to task-oriented practice. 2. Clearly define the role expectations and tasks of each member of the team and focus on the important contribution each makes to the overall quality of care. It is vitally important that each member of the team feel valued and that their skill sets are maximized to the full extent of their scope of practice. 3. Emphasize the leadership role of the RN. Acknowledge that most staff RNs do not know how to lead or delegate and must be educated and coached in these skills. Changing CDMs requires expertise in managing change, delineation of new role expectations, and skill-building education. Leaders must listen carefully to the perspectives of team members and be willing to adopt, adapt, or abandon the plan accordingly. Finally, CDMs should be developed with the patient population in mind and should maximize use of nursing resources to the fullest extent of scope of practice and education.

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